Healthcare Provider Details

I. General information

NPI: 1821061680
Provider Name (Legal Business Name): YELENA M. POPOVA PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3234 MARYSVILLE BLVD
SACRAMENTO CA
95815-1411
US

IV. Provider business mailing address

200 OCEANGATE SUITE 100
LONG BEACH CA
90802-4317
US

V. Phone/Fax

Practice location:
  • Phone: 916-646-1200
  • Fax: 877-860-2703
Mailing address:
  • Phone: 562-499-6191
  • Fax: 877-860-2703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18255
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA18255
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: